Provider Demographics
NPI:1033867049
Name:CANIN, TRACY L (MA, ATR-BC, LCAT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:CANIN
Suffix:
Gender:F
Credentials:MA, ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-0778
Mailing Address - Country:US
Mailing Address - Phone:516-695-3550
Mailing Address - Fax:
Practice Address - Street 1:3A KNOLL TOP RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1403
Practice Address - Country:US
Practice Address - Phone:516-695-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000277221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist